Isolated Ocular Motor Nerve Palsies

Size: px
Start display at page:

Download "Isolated Ocular Motor Nerve Palsies"

Transcription

1 539 Nathan H. Kung, MD 1 Gregory P. Van Stavern, MD 2 1 Department of Neurology, Washington University in St. Louis, St. Louis, Missouri 2 Department of Ophthalmology, Washington University in St. Louis, St. Louis, Missouri Address for correspondence Gregory P. Van Stavern, MD, Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8096, Saint Louis, Missouri, ( VanStavernG@vision.wustl.edu). Semin Neurol 2015;35: Abstract Keywords ocular motility diplopia microvascular ischemia The approach to the adult patient aged 50 years and older with an isolated ocular motor nerve palsy begins with a thorough assessment of the patient s historyandneuroophthalmic examination. The goal is localization to the specific dysfunctional nerve and generation of a differential diagnosis. In this context, isolated means a single ocular motor nerve (oculomotor, trochlear, or abducens) is affected and there are no associated or localizing neurologic signs or symptoms. Following the accurate identification of the involved nerve, one can then use the best available evidencetodeterminetheyieldofneuroimagingandother ancillary testing in ruling out structural or other malignant causes of isolated palsies. If the cause is determined to be microvascular, then the focus turns to identification of associated risk factors, the likelihood of improvement, and the use of patching, prisms, or surgical strategies to correct residual diplopia. We will discuss each of these steps and review the approach to each of the isolated ocular motor nerve palsies. Approach to Diplopia and Localization Binocular diplopia due to ocular misalignment may occur due to lesions of the supranuclear, internuclear, nuclear, intramedullary fascicular, or extramedullary formed portions of a cranial nerve. Once the cranial nerve reaches its target, a disorder of the neuromuscular junction or extraocular muscle An isolated ocular motor nerve palsy is defined as dysfunction of a single ocular motor nerve (oculomotor, trochlear, or abducens) with no associated or localizing neurologic signs or symptoms. When occurring in patients aged 50 or older, the most common cause is microvascular ischemia, but serious etiologies such as aneurysm, malignancy, and giant cell arteritis should always be considered. In this article, the authors review the clinical approach, anatomy, and differential diagnosis of each isolated ocular motor nerve palsy and discuss the clinical characteristics, pathophysiology, and treatment of microvascular ischemia. itself may also cause diplopia. Accordingly, the approach to the adult patient with the new onset of diplopia begins with a thorough assessment of the history and neuro-ophthalmic examination. 1 5 The important questions in assessing diplopia include whether it is monocular or binocular; whether the diplopia is primarily horizontal, torsional, or vertical; in which direction of gaze the diplopia is maximal; whether there is any fatigability or diurnal variation in the severity of the diplopia; whether there is any associated ptosis or facial muscle weakness; whether it is constant or intermittent; and whether there are any other localizing symptoms such as involvement of other cranial nerves, limb weakness, ataxia, proptosis, or impairment in visual acuity or color perception (see Table 1). The abrupt onset of sustained diplopia is more suggestive of a microvascular event than progressive or chronic intermittent diplopia. As a general rule, all patients over the age of 50 years should also be assessed for signs and symptoms of giant cell arteritis, which can occasionally present with diplopia. 6 The most important initial question in evaluating double vision is to determine whether it is monocular or binocular in etiology. Ask the patient whether the symptom resolves by closing either eye. If closing either eye resolves the abnormality, this indicates misalignment of the eyes (strabismus). If closing only one particular eye resolves the diplopia, this suggests an ocular problem isolated to the affected eye such as refractive error or ocular surface disease. Issue Theme Neuro-Ophthalmology; Guest Editor: Beau B. Bruce, MD, PhD Copyright 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) DOI /s ISSN

2 540 Kung, Van Stavern Table 1 Diplopia: Historical clues to etiology Monocular or binocular Horizontal, vertical, or torsional Gaze direction of maximal diplopia Fatigability or diurnal variation Presence of ptosis or facial weakness Constant or episodic Presence of any other neurologic symptoms Binocular diplopia should be further characterized as horizontal, suggesting sixth nerve involvement (lateral recti); vertical, suggesting third or fourth nerve involvement (vertical recti and obliques); or predominantly torsional, suggesting fourth involvement (superior oblique). If a patient can identify the direction of gaze with maximal diplopia, knowledge of the yoked eye muscles in each cardinal direction of gaze can help to identify the affected muscle and nerve (see Fig. 1). Horizontal diplopia worse in right gaze suggests weakness of the right lateral rectus or left medial rectus, whereas horizontal diplopia worse in left gaze suggests weakness of the left lateral rectus or right medial rectus. A unilateral weakness of eye movement should help determine which muscle is affected. Notably, each eye should be tested independently to remove pseudorestrictive effects related to alternating monocular fixation and vergence when both eyes are open. When red flag symptoms other than diplopia are prominent, common mimics of isolated ocular motor nerve palsies should be considered (see Table 2). The presence of fatigability, ptosis, facial weakness, proximal weakness, and diurnal variation with symptoms worse late in the day suggests myasthenia gravis. The presence of proptosis, periorbital edema, and diurnal variation with symptoms early in the morning suggests thyroid eye disease, which can occur even in the clinically euthyroid state. 7 The presence of afferent visual impairment with optic nerve involvement suggests an orbital apex syndrome. 8 The gradual onset of episodic diplopia with longstanding transient diplopia and head tilt suggests decreasing fusional reserve and decompensated congenital strabismus. 2 In hospitalized patients, the concurrent onset of ophthalmoplegia with altered mental status, ataxia, and nystagmus suggests thiamine deficiency, which may occur in alcoholics, malnourished patients, and other at-risk patient populations. 9 A similar picture could be seen with anticonvulsant intoxication. 10 The combination of areflexia, bulbar weakness, and diplopia suggests Miller-Fisher syndrome, a subtype of Guillain-Barré syndrome. 11 Wound or foodborne botulism Fig. 1 Yoked muscles in each cardinal direction of gaze. SR, superior rectus; IO, inferior oblique; IR, inferior rectus; LR, lateral rectus; MR, medial rectus. Available at: Accessed March 23, (Reprinted with permission from Ted Montgomery.)

3 Kung, Van Stavern 541 Table 2 Diplopia red flags : Clues to a nonmicrovascular etiology Ptosis, fatigability, facial weakness Proptosis, periorbital edema Afferent visual impairment Ataxia, ophthalmoplegia Areflexia, facial weakness New centrally acting medications Fig. 2 The primary and secondary actions of each extraocular muscle. SR, superior rectus; IO, inferior oblique; IR, inferior rectus; LR, lateral rectus; MR, medial rectus. should be considered in adults with diplopia and descending weakness. 12 Other less common causes of diplopia such as Friedrich ataxia, Kearns-Sayre syndrome, Wilson disease, Whipple disease, or other metabolic conditions should also be considered. 13 Anatomy of the Ocular Motor Nerves The oculomotor nerve innervates the superior rectus, inferior rectus, medial rectus, and inferior oblique. The trochlear nerve innervates the superior oblique, and the abducens nerve innervates the lateral rectus. The primary and secondary actions of each muscle are depicted in Fig. 2 and described in Table 3. Of note, in-cyclotorsion describes rotation of the superior pole of each eye toward the nose, whereas ex-cyclotorsion describes rotation of the superior pole toward the lateral canthus. The third nerve nuclei are situated in the upper midbrain at the level of the superior colliculus, near the vertical midline, just anterior to the cerebral aqueduct. Each levator palpebrae is supplied by one unpaired midline nucleus, but each ocular muscle supplied by the third nerve has a paired subnucleus on each side of the midline. The exception is the medial rectus, which has three subnuclei on each side. The axons arising from each subnucleus (collectively known as the third nerve fascicle) then travel ipsilaterally in a topographic distribution through the anterior portions of the midbrain, passing through the red nucleus and cerebral peduncle, to form the third nerve within the subarachnoid space. The exception is the superior rectus subnucleus, which sends its axons contralaterally through the opposite superior rectus subnucleus before joining that contralateral third nerve fascicle going through the anterior midbrain into the subarachnoid space. Once in the subarachnoid space, the third nerve passes between the superior cerebellar and posterior cerebral arteries and travels anteriorly near the posterior communicating artery and uncus of the ipsilateral temporal lobe. It then pierces the dura and travels in the ipsilateral cavernous sinus on its way to the superior orbital fissure, where the nerve fibers enter the orbit and meet their respective target muscles within the region of the orbital apex The fourth nerve nucleus is situated in the lower midbrain at the level of the inferior colliculus, near the midline, just anterior to the cerebral aqueduct. There is one nucleus on each side, corresponding to the cell bodies of the neurons comprising each trochlear nerve. In contrast to the third nerve fascicles, which course anteriorly, the fourth nerve fascicles course posteriorly around the cerebral aqueduct and cross the midline posteriorly to emerge from the brainstem contralaterally just past the vertical midline. The subarachnoid segment of the trochlear nerve then courses around the midbrain and passes anteriorly along the edge of the cerebellar tentorium. When it pierces the dura, it then travels in this contralateral cavernous sinus on its way to the superior orbital fissure, where it meets the superior oblique muscle within the region of the orbital apex The sixth nerve nucleus is situated in the lower pons, near the midline, just anterior to the floor of the fourth ventricle. There is one nucleus on each side, corresponding to the cell bodies of the neurons comprising each abducens nerve. Of interest is that the fascicle of the seventh nerve courses just posterior to the nucleus of the sixth nerve, such that it is nearly impossible to lesion the sixth nerve nucleus without causing an ipsilateral seventh nerve palsy. 8 The sixth nerve fascicles course anteriorly through the medial lemniscus and Table 3 The primary and secondary actions of each extraocular muscle Nerve Muscle Primary action Secondary action Oculomotor nerve Superior rectus Elevation In-cyclotorsion Inferior rectus Depression Ex-cyclotorsion Medial rectus Adduction Inferior oblique Ex-cyclotorsion Elevation Trochlear nerve Superior oblique In-cyclotorsion Depression Abducent nerve Lateral rectus Abduction

4 542 Kung, Van Stavern emerge anteriorly at the ipsilateral pontomedullary junction. The nerve then ascends in the subarachnoid space between the pons and clivus and passes anteriorly through Dorello s canal. It then pierces the dura and travels in this ipsilateral cavernous sinus on its way to the superior orbital fissure, where it meets the lateral rectus muscle within the region of the orbital apex Each ocular motor nerve can be affected anywhere along its course, from the nucleus, to the fascicle, to the nerve in the subarachnoid space, to the nerve in the cavernous sinus, all the way into the orbital apex. When multiple cranial nerves are involved, the localization may be evident based on knowledge of where nerves travel together, or based on other localizing clues. For example, the cavernous sinus contains cranial nerves (CNs) III, IV, VI, V1, V2, and sympathetic autonomic fibers traveling along the carotid artery. The orbital apex contains CNs II, III, IV, VI, V1, as well as the sympathetic autonomic fibers. Diffuse infiltrative processes such as lymphoma or carcinomatosis may involve multiple CNs, including the lower CNs such as VII, IX, X, or XII, within the subarachnoid space on the leptomeningeal surface of the brain. Otorrhea with sixth nerve palsy suggests petrous apicitis, whereas the presence of hemiparesis or ataxia suggests brainstem involvement When an ocular motor nerve is affected in isolation, however, there are generally few clues to its localization, and neuroimaging may be required to assist in the localization of the injury. Critical factors that inform the need for neuroimaging and contribute to the differential diagnosis include the patient s age, the tempo and duration of onset, the presence or absence of pain, any associated medical conditions, and for third nerve palsy, the status of the pupil. 1 Evaluation of Oculomotor Nerve Palsy Physical Examination Third nerve palsies, when complete or nearly complete, cause the affected eye to adopt a down-and-out position due to intact function of the superior oblique and lateral rectus, which tend to depress and abduct the eye. Significant weakness of elevation, depression, and adduction is expected. Many third nerve palsies are incomplete, with not all innervated muscles affected or less than complete weakness of each affected muscle. Isolated weakness of a single extraocular muscle is rare, however, and suggests an alternate etiology such as myasthenia gravis, thyroid eye disease, local restriction from trauma, or an internuclear ophthalmoplegia. 1 Similarly, isolated pupillary dilation rarely implies third nerve dysfunction, and usually represents tonic pupil, pharmacologic mydriasis, or even benign physiologic anisocoria. 18 In the setting of adduction weakness from a third nerve palsy, the residual function of the fourth nerve should be assessed by asking the patient to abduct the eye and then depress it, looking carefully at scleral vessels for in-cyclotorsion mediated by the superior oblique. Etiologies Oculomotor dysfunction may result from many causes, including microvascular ischemia, aneurysm, head trauma, neoplasm, syphilis, herpes zoster, meningitis, encephalitis, sarcoidosis, vasculitis, lupus, multiple sclerosis, neurosurgical intervention, myelography, influenza, Tolosa-Hunt syndrome, and Paget s disease To provide scope, of the 1,130 retrospective cases of third nerve palsy reported by the Mayo clinic from the 1950s to the 1980s for patients of all age groups, 270 were due to undetermined causes, 225 were due to microvascular ischemia, 179 were due to aneurysm, 166 were due to head trauma, 141 were due to neoplasm, and 149 were due to other causes. 22 It should be noted that these cases were not evaluated by modern neuroimaging techniques; however, so small compressive lesions may have been missed. This same limitation applies to the retrospective series of fourth and sixth nerve palsies from the Mayo clinic described in later sections of this review. Many of the above causes of third nerve palsy will have overt systemic manifestations with additional signs and symptoms. 23 When occurring in clinical isolation in adults 50 years of age and older, however, microvascular ischemia and aneurysm comprise a majority of cases and therefore warrant special discussion The third cranial nerve is unique due to its association with the urgent, potentially life-threatening complication of an enlarging aneurysm, classically of the posterior communicating artery. Fibers mediating pupillary constriction course along the outer portions of the nerve and thus suggest impingement when affected. 17 Therefore, patients with third nerve palsy and any degree of pupillary involvement require urgent vascular imaging of the head to rule out an expanding aneurysm, though approximately one-third of patients with microvascular ischemia may also have some involvement of the pupil. In these cases, however, the degree of anisocoria is typically < 1 mm, and the pupil remains reactive. 27,28 Patients with preserved pupillary function may still be at risk of harboring an aneurysm if they have incomplete paresis of the innervated extraocular muscles or if the ptosis is not complete because the third nerve palsy may still be in progression. 29 The patients at lowest risk of harboring an aneurysm are those with complete preservation of pupillary function in the setting of complete ptosis, complete paresis of the innervated extraocular muscles, and appropriate vasculopathic risk factors to suggest microvascular ischemia. These patients still require close clinical follow-up, however, to ensure that pupillary involvement does not ensue. 29 Although the details of the extraocular muscle examinations are not fully reported, two large retrospective series suggest that between 2 to 3% of patients harboring an aneurysm may have no pupillary involvement. Rucker reported a total of 4 out of 114 patients with aneurysmal compression of the third nerve that did not have pupillary involvement. 19,20 Keane reported that only 2 of 143 patients with aneurysmal compression of the third nerve did not have pupillary involvement. 27 Neuroimaging Three recent studies have prospectively assessed the yield of urgent neuroimaging in evaluating acute isolated third nerve palsies in patients 50 years of age or older. These three studies performed magnetic resonance imaging (MRI) examinations

5 Kung, Van Stavern 543 on consecutive patients with acute isolated third, fourth, or sixth nerve palsies who presented without trauma, recent neurosurgical intervention, active malignancy, or any other localizing signs and symptoms other than nonspecific headache or pain. The series of third nerve palsy patients are presented here, and the series of fourth and sixth nerve palsy patients are presented under their respective sections. Chou et al found that 4 of 29 cases of acute isolated third nerve palsy (14%) were due to causes other than microvascular ischemia. 24 Specifically, one was due to neoplasm, one was due to a brainstem infarct, and two were due to aneurysm. All other cases (86%) were determined to be due to microvascular ischemia. Notably, seven of nine patients with pupillary involvement were determined to have microvascular ischemia, with > 2 mm of anisocoria in three of these seven patients. One patient with aneurysm had pupillary sparing with only partial extraocular muscle involvement. Murchison et al found no structural etiologies in 14 consecutive patients with acute isolated third nerve palsy. 25 Tamhankar et al found that 3 of 22 cases (14%) were due to causes other than microvascular ischemia, including pituitary apoplexy and idiopathic enhancement of the third nerve, which later resolved. 26 Jacobson and Trobe previously explored the risk of harboring an aneurysm in the setting of a negative magnetic resonance angiogram (MRA). 30 In their literature review, they found that most well-documented posterior communicating aneurysms causing third nerve palsies were 5mm in size rather than < 5 mm in size (91.3% vs. 8.7%). Furthermore, when compared directly with catheter angiography, MRA was able to pick up nearly all aneurysms 5mm in size versus < 5 mm (97% vs. 53.6%). Because the risk of rupture is lower for smaller aneurysms, however, a mathematical interpretation of the data suggests that a properly performed and interpreted MRA will overlook only 1.5% of aneurysms which cause third nerve palsy and that will go on to rupture during the next 8 years if untreated. Clinical follow-up should help to alleviate concerns of an undetected enlarging aneurysm, as affected patients should fail to recover or begin to develop signs of aberrant regeneration. 29 It should be noted that this review was performed before the advent of computed tomography (CT) angiography and higher resolution magnetic resonance (MR) angiography techniques, which likely have greater sensitivity for detecting small aneurysms. Evaluation of Trochlear Nerve Palsy Physical Examination Trochlear nerve palsies result in vertical diplopia with a resting hypertropia (i.e., relative elevation) of the affected eye. Alternate cover testing using prisms remains the gold standard for diagnosing fourth nerve palsies. Prisms are not always readily available, however, and require some expertise to use. When ocular misalignment is mild or not apparent from viewing resting eye positions, vertical diplopia worst when placing the right eye in the down-and-in position suggests involvement of the right superior oblique, whereas vertical diplopia worst when placing the left eye in the downand-in position suggests involvement of the left superior oblique. Sometimes, the use of a red-colored lens traditionally placed over the right eye can help the patient to distinguish the direction of gaze that gives them the greatest degree of misalignment. The affected eye cannot always reliably be distinguished using this red lens test, however, due to the effects of alternating monocular fixation. Resolution of diplopia with head tilt away from a hypertropic eye suggests that the diplopia may be the result of a fourth nerve palsy in the higher eye. A left fourth nerve palsy should also show an increased degree of left hypertropia when looking to the right, whereas a right fourth nerve palsy should show an increased degree of right hypertropia when looking to the left. 31,32 Use of a Maddox rod can help to confirm a fourth nerve palsy by determining ocular cyclotorsion. When holding the Maddox rod with lines oriented in the up-and-down direction, the patient will see a horizontal line in that eye. When held in front of a hypertropic eye, the patient with fourth nerve palsy will see the line as angled downwards nasally (representing ex-cyclotorsion of the eye), whereas the patient with central skew deviation will see the line as angled upwards nasally (representing in-cyclotorsion of the eye). Etiologies Trochlear nerve dysfunction has a wide variety of etiologies, including head trauma, malignancy, microvascular ischemia, encephalitis, lupus, herpes zoster, stroke, multiple sclerosis, postviral, and aneurysm To provide scope, of the 578 retrospective cases of fourth nerve palsy reported by the Mayo clinic from the 1950s to the 1980s for patients of all age groups, 186 were due to undetermined causes, 169 were due to head trauma, 103 were due to presumed microvascular ischemia, 28 were due to neoplasm, 5 were due to aneurysm, and 87 were due to other causes, including congenital palsy with decompensation in 79 of these 87 cases. 22 Many of these causes of fourth nerve palsy will have overt systemic manifestations with additional signs and symptoms. When head trauma and congenital causes are excluded, however, most fourth nerve palsies occurring in clinical isolation in adults 50 years of age and older are due to presumed microvascular ischemia. 22,33 Neuroimaging In the subsets of patients with acute isolated fourth nerve palsy in the three previously mentioned studies, Chou et al found that only 1 of 14 cases was due to a cause other than microvascular ischemia. Specifically, only one neoplasm was detected. All other cases (93%) were determined to be due to microvascular ischemia. 24 Murchison et al assessed 27 consecutive patients and did not detect any diagnoses other than microvascular ischemia. 25 Tamhankar et al found that 3 of 25 cases (12%) were due to causes other than microvascular ischemia, including one patient with an infarct in the dorsal midbrain. 26 Evaluation of Abducens Nerve Palsy Physical Examination Abducens nerve palsies result in horizontal diplopia and will show a unilateral weakness of abduction in the affected eye. It

6 544 Kung, Van Stavern is important to test each eye independently because of the pseudo-restrictive effects of alternating monocular fixation and vergence when both eyes are open. Etiologies Sixth cranial nerve dysfunction has many causes, including head trauma, malignancy, microvascular ischemia, aneurysm, meningitis, encephalitis, multiple sclerosis, syphilis, poliomyelitis, mastoiditis, cavernous-carotid fistula, idiopathic intracranial hypertension, intracranial hypotension, subarachnoid hemorrhage, intraparenchymal hematoma, and neurosurgical intervention In the retrospective cases of sixth nerve palsy reported by the Mayo clinic from the 1950s to the 1980s for patients of all age groups, 504 were due to an undetermined cause, 413 were due to neoplasm, 287 were due to head trauma, 240 were due to presumed microvascular ischemia, 58 were due to aneurysm, and 417 were due to other causes. 22 Neuroimaging Chou et al found that 4 of 23 cases of acute isolated sixth nerve palsy (17%) were due to causes other than microvascular ischemia, including one neoplasm, one brainstem infarct, one new diagnosis of multiple sclerosis, and one case of unexpected pituitary apoplexy. 24 Murchison et al detected only one relevant structural finding, a pontine hemorrhage, in 52 consecutively studied patients (2%). Three incidental findings were noted, however, including a contralateral acoustic neuroma, a contralateral meningioma, and a maxillary sinus tumor. 25 Tamhankar et al determined that 12 of 62 cases (19%) were due to causes other than microvascular ischemia, including one case of cavernous sinus B cell lymphoma, one case of petroclival meningioma, and three cases of GCA diagnosed on the basis of an elevated erythrocyte sedimentation rate (ESR), elevated C-reactive protein (CRP), and positive temporal artery biopsies. 26 In one additional study of patients with acute isolated sixth nerve palsy, Bendszus et al prospectively assessed 43 consecutive patients aged 2 to 82 years and found a causative lesion in 63% of patients. 34 The median age of the study group was 48 years, however, younger than in the three previously mentioned prospective neuroimaging studies that only evaluated patients aged 50 years and older. Neuroimaging Recommendations Given the above recent prospective data and unique disease associations of each particular cranial nerve palsy, a reasonable conservative approach would be to follow the guidelines previously proposed by Murchison et al. 25 Patients should receive an MRI in the setting of an acute isolated third, fourth, or sixth cranial nerve palsy if any of the following criteria are met: (1) age < 50 years, (2) found to have a pupil-involving or any pupil-sparing partial third nerve palsy, (3) known to have a history of cancer of any type at any time, or (4) found to have any other concerning or localizing neurologic signs or symptoms (see Table 4). Table 4 Neuroimaging recommendations Magnetic resonance brain and orbits with and without gadolinium: If aged < 50 years If found to have pupil-involving or pupil-sparing partial third nerve palsy If known to have cancer of any type at any time If any other localizing signs or symptoms If not improved by 1 month If not resolved by 3 months A wider approach to neuroimaging with MRI/MRA performed on all or nearly all patients presenting with acute isolated third, fourth, and sixth nerve palsies is also reasonable if the resources are available and both the physician and patient desire a more expeditious and definitive initial evaluation. 35 A referral to a neuro-ophthalmologist could also be considered to screen for subtle motility deficits that might implicate another ocular motor nerve or suggest an alternate diagnosis. With all ocular motor nerve palsies, MRI is the preferred neuroimaging modality. Fat-saturated orbital imaging should also be included, as this sequence will allow better evaluation of the cavernous sinus and intraorbital portions of the ocular motor nerves. Once the neuroimaging is performed, it should be personally reviewed; one study found that 38% of patients arriving to an academic neuro-ophthalmology practice with pre-existing neuroimaging had incorrect or suboptimal imaging studies (e.g., CTwas performed where MRI was required, or where the image quality was inadequate to definitively rule out a suspected lesion). 36 Studies have also shown that radiologists or observers without specific training in neuroradiology may miss relevant findings on MRI or MRA, especially when the radiologist is given insufficient information to focus on the area of suspected pathology. 37 If neuroimaging is initially deferred, a lack of resolution by 3 months, or failure to demonstrate any recovery by one month, should prompt further investigations including neuroimaging. 35 Of note, there have been several reported cases of spontaneously remitting sixth nerve palsies in the setting of skull base tumors, however, thereby emphasizing the need to take all clinical factors into account when determining the need for neuroimaging. 38 High-Resolution Neuroimaging Techniques Many clinical studies of the yield of neuroimaging, including several of the studies previously discussed, have relied on the use of traditional MRI techniques and sequences to evaluate for tumors, aneurysms, and strokes, largely considered to be the most worrisome structural abnormalities in the setting of a cranial nerve palsy. However, more recent high-resolution three-dimensional (3D) sequences, including constructive interference in the steady state (CISS), fast imaging employing

7 Kung, Van Stavern 545 steady-state acquisition (FIESTA), turbo-spin-echo with variable flip angle (SPACE), and balanced turbo field echo (BTFE) are now able to reliably visualize the entire course of the ocular motor nerves from their exit in the brainstem all the way through to the superior orbital fissure and into the orbital apex Each segment can then be studied in detail, including the cisternal, dural, interdural (cavernous), foraminal, and extraforaminal portions of the nerve. The spatial resolution of these techniques can reach 0.6 mm or better, and even the smallest nerves such as the fourth and sixth can often be visualized (see Fig. 3). 42,43 The course of the third nerve is readily visualized on these sequences. For example, using 0.6-mm slices, 3D-CISS can demonstrate the exact relationship of the third nerve to the posterior communicating and superior cerebellar arteries in the setting of an aneurysm 39 ; 3D-CISS can also reveal the precise anatomy of the cavernous sinus and show the relationship of each nerve to local masses or the internal carotid artery. 44 With postcontrast high-resolution sequences, idiopathic inflammation and enhancement of the nerves might also be better visualized, such as in Tolosa-Hunt syndrome 39 or in recurrent ophthalmoplegic cranial neuropathies. 45 Although adding to the time and complexity of MRI examinations, these sequences demonstrate the increasing capacity of technology to aid our understanding of otherwise cryptogenic or idiopathic ocular motor nerve palsies. Characteristics of Microvascular Ischemia The diagnosis of microvascular ischemia is often presumptive and clinically based, as there is no known laboratory or imaging correlate. Although a general consensus exists in the literature about the features that a microvascular palsy should exhibit, there are no formalized diagnostic criteria for this disorder. 46 Furthermore, the certainty of the diagnosis cannot be fully determined at the initial presentation. Rather, the diagnosis is fully realized when the patient s clinical history and course conform over time to the expected natural history of a microvascular palsy. Signs and symptoms of multiple cranial neuropathy, myasthenia gravis, thyroid eye disease, head trauma, congenital nerve palsy, giant cell arteritis, multiple sclerosis, syphilis, and Lyme disease should remain absent at follow-up. 47 Microvascular palsies are thought to occur most often in adults 50 years of age or older 48 with existing vascular risk factors such as hypertension, hyperlipidemia, 50 diabetes, 47,49,50 left ventricular hypertrophy, 47 and smoking. 51 The onset should be acute to subacute, but when examined early in the course of their illness, patients may show progression in ophthalmoparesis for a period of 2 to 4 weeks Systemic symptoms are typically absent, but up to two-thirds of patients may report pain, typically in the ipsilateral brow, which may occur before, during, or after the onset of diplopia. 26,52,55 Following a period of relative stability, the patient sdiplopia should then begin to resolve, with recovery expected in 70% or more of cases, 21,22,51 typically within a period of approximately 3 months In clinical practice, failure to completely recover in a reasonable timeframe (<3 to 6 months) should raise concern for an alternate etiology. Recurrence of microvascular palsies has been reported. In one long-term retrospective review of 59 patients with Fig. 3 High-resolution imaging of (A) the oculomotor nerve in the subarachnoid space, (B) the oculomotor nerve as it courses near the posterior cerebral artery and superior cerebellar artery, (C) the trochlear nerve in the subarachnoid space, and (D) the abducens nerve as it exits the brainstem. CN, cranial nerve; SCA, superior cerebellar artery; PCA, posterior cerebellar artery.

8 546 Kung, Van Stavern microvascular sixth nerve palsy, 16 patients (31%) experienced 24 recurrent events either in the same or contralateral eye. Most patients experienced only one recurrence, but three patients had two recurrences and one patient had four recurrences. 51 Using a different methodology, Keane found that 26 ocular motor nerve palsies had previously occurred within his cohort of 141 patients with acute diabetic third nerve palsy. 27 Pathology of Microvascular Ischemia Little is known about the actual pathophysiology of microvascular ocular motor nerve palsies, presumably because the disease is inherently self-limited and not life-threatening. Accordingly, few patients have been examined at autopsy. In 1957, Dreyfus et al 56 reported a 62-year-old diabetic woman with acute left third nerve palsy who expired due to an enlarging neck hematoma following an open left carotid arteriogram to rule out aneurysm. At autopsy, microscopic sections from the intracavernous portion of the left oculomotor nerve revealed areas of extensive myelin loss and fragmentation of the remaining nerve sheaths. Examination of the vasa nervorum revealed thickening and hyalinization of the blood vessels, suggestive of chronic vascular changes. No local vascular occlusions were noted. Although the most prominent changes were found in the nerve sheath myelin, fragmented axon particles were also noted in local macrophages. In 1970, Asbury et al 57 reported an 88-year-old woman with a history of prior right-sided microvascular third nerve palsy who developed a left-sided microvascular third nerve palsy one month prior to her death from congestive heart failure. On her autopsy, the most prominent finding was a focal zone of demyelination with preserved underlying axons located in the second quarter of the intracavernous segment of the left third nerve. Notably, the area of demyelination appeared to lie in a watershed vascular zone between which branches from the anterior and posterior circulation met and supplied the third nerve. Arterial hyalinization was observed in the vasa nervorum, suggestive of chronic vascular change. Weber et al 58 reported in 1970 an autopsy on a third patient with a history of presumed diabetic oculomotor palsy 5 months prior to death. Similar to the above cases, the patient was found to have a segment of the third nerve with a significant reduction in myelin staining with lesser injury to the underlying axons. In contrast to prior cases, this lesion was found in the subarachnoid portion of the nerve rather than in the intracavernous portion of the nerve. Analysis of the vasa nervorum showed hyaline thickening. Interestingly, although an etiology for the ipsilateral brow pain typically associated with microvascular palsies was not discovered in the above autopsy series, anatomical studies in other mammals have revealed trigeminal sensory fibers that travel through the substance of the oculomotor nerve. 59 microvascular nerve palsies. As previously mentioned, spontaneous recovery is expected in 70% or more of cases of microvascular ischemia, 21,22,51 typically within a period of 3 months. 47,52 54 Therefore, the treatment of microvascular ischemia largely centers on the use of patching, prisms, and strabismus surgery to relieve the patient s diplopia. 60 Only one study has evaluated the effect of aspirin in the setting of an ischemic nerve palsy. This retrospective casecontrol study found that a similar proportion of patients with microvascular nerve palsies were already taking aspirin compared with a group of age- and gender-matched controls, suggesting that aspirin use was not fully protective against having a microvascular palsy. 61 For patients in the acute period of their illness, patching or fogging of one eye with handmade or commercial solutions is typically the most cost-effective and reasonable initial option. In fact, patients may arrive in the office with self-constructed patches, having discovered the binocular nature of their diplopia. Monocular occlusion with a patch is a simple method of preventing diplopia. Occasionally, an occlusive (black) contact lens can be used to allow for peripheral vision while blocking central diplopia. In children under the age of 6, sustained patching can result in amblyopia, and such management should be done in conjunction with a pediatric ophthalmologist. 62,63 Adult patients can safely patch either eye without concern for amblyopia. Another common concern is the loss of binocular fusion due to monocular patching, but this does not occur with patching for weeks to months. Most patients with central fusion disruption have had severe head trauma 64 or prolonged monocular sensory deprivation for months to years (e.g., dense unilateral cataract 65 ). Ocular motility exercises are sometimes also recommended following an ischemic palsy, but there are no clinical data to support motility exercises for this diagnosis. 66 For patients who require or prefer binocular vision, temporary stick-on prisms can be used over a patient s existing glasses or over clear nonprescription spectacles. Due to the likelihood of spontaneous improvement in ophthalmoparesis over the short term, the least amount of prism that allows the patient to achieve binocular fusion should be used. For patients with both vertical and horizontal components of diplopia, the vertical misalignment should be corrected first, as this axis has the least amount of fusional reserve. Large angles of strabismus are typically not amenable to correction with prism. Finally, for patients with fixed weakness several months following their ischemic nerve palsy, glasses with ground-in prism correction or strabismus surgery should be considered to help patients minimize residual diplopia. 60 Minimizing diplopia in the straight-ahead and downward positions typically provides the most benefit in the patient s level of function for reading, navigating, and other daily tasks. Treatment of Microvascular Ischemia There have been no treatment trials evaluating interventions directed toward hastening or improving the recovery of Summary In patients aged 50 years or older, isolated ocular motor nerve palsies are most likely due to microvascular ischemia, but

9 Kung, Van Stavern 547 serious etiologies such as aneurysm and malignancy should be ruled out either with neuroimaging or close clinical followup. Giant cell arteritis should always be considered in patients > 50 years of age. The treatment of an ischemic nerve palsy is symptomatic, to relieve the patient s symptoms of diplopia, as no other medical therapies have been proven to be of benefit. Patients who are not known to have vasculopathic risk factors should be examined for hypertension, diabetes, and hyperlipidemia, and those who currently smoke should be advised to quit for general health. Aspirin has not been prospectively studied in patients with ischemic nerve palsies, but may be beneficial for overall health prevention. Acknowledgments The authors gratefully acknowledge the assistance of Manu Goyal, MD (Department of Radiology, Washington University in St. Louis, Missouri, USA) in reviewing the radiology discussion and preparing the high-resolution cranial nerve images. References 1 Friedman DI. Pearls: diplopia. Semin Neurol 2010;30(1): Danchaivijitr C, Kennard C. Diplopia and eye movement disorders. J Neurol Neurosurg Psychiatry 2004;75(Suppl 4):iv24 iv31 3 Pelak VS. Evaluation of diplopia: an anatomic and systemic approach. Hosp Physician 2004;40(3): Brazis PW, Lee AG. Binocular vertical diplopia. Mayo Clin Proc 1998;73(1): Buracchio T, Rucker JC. Pearls and oy-sters of localization in ophthalmoparesis. Neurology 2007;69(24):E35 E40 6 Dasgupta B, Borg FA, Hassan N, et al; BSR and BHPR Standards, Guidelines and Audit Working Group. BSR and BHPR guidelines for the management of giant cell arteritis. Rheumatology (Oxford) 2010;49(8): Phelps PO, Williams K. Thyroid eye disease for the primary care physician. Dis Mon 2014;60(6): Azarmina M, Azarmina H. The six syndromes of the sixth cranial nerve. J Ophthalmic Vis Res 2013;8(2): Donnino MW, Vega J, Miller J, Walsh M. Myths and misconceptions of Wernicke s encephalopathy: what every emergency physician should know. Ann Emerg Med 2007;50(6): Praveen-kumar S, Desai M. Ocular motor abnormalities in a patient with phenytoin toxicity case report and minireview. Clin Neurol Neurosurg 2014;127: Wakerley BR, Uncini A, Yuki N; GBS Classification Group; GBS Classification Group. Guillain-Barré and Miller Fisher syndromes new diagnostic classification. Nat Rev Neurol 2014;10(9): Centers for Disease Control and Prevention. Botulism. Available at: Accessed March 15, Jordan JT, Samuel G, Vernino S, Muppidi S. Slowly progressive ataxia, neuropathy, and oculomotor dysfunction. Arch Neurol 2012;69(10): Prasad S, Volpe NJ. Paralytic strabismus: third, fourth, and sixth nerve palsy. Neurol Clin 2010;28(3): Adams ME, Linn J, Yousry I. Pathology of the ocular motor nerves III, IV, and VI. Neuroimaging Clin N Am 2008;18(2): , x x 16 Bennett JL, Pelak VS. Palsies of the third, fourth, and sixth cranial nerves. Ophthalmol Clin North Am 2001;14(1): , ix 17 Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology. Philadelphia, PA: Lippincott Williams & Wilkins; 2011: Evans RW, Jacobson DM. Transient anisocoria in a migraineur. Headache 2003;43(4): Rucker CW. Paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol 1958;46(6): Rucker CW. The causes of paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol 1966;61(5 Pt 2): Rush JA, Younge BR. Paralysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 cases. Arch Ophthalmol 1981;99(1): Richards BW, Jones FR Jr, Younge BR. Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol 1992;113(5): Bruce BB, Biousse V, Newman NJ. Third nerve palsies. Semin Neurol 2007;27(3): Chou KL, Galetta SL, Liu GT, et al. Acute ocular motor mononeuropathies: prospective study of the roles of neuroimaging and clinical assessment. J Neurol Sci 2004;219(1-2): Murchison AP, Gilbert ME, Savino PJ. Neuroimaging and acute ocular motor mononeuropathies: a prospective study. Arch Ophthalmol 2011;129(3): Tamhankar MA, Biousse V, Ying GS, et al. Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes: a prospective study. Ophthalmology 2013;120(11): Keane JR. Third nerve palsy: analysis of 1400 personally-examined inpatients. Can J Neurol Sci 2010;37(5): Jacobson DM. Pupil involvement in patients with diabetes-associated oculomotor nerve palsy. Arch Ophthalmol 1998;116(6): Brazis PW. Isolated palsies of cranial nerves III, IV, and VI. Semin Neurol 2009;29(1): Jacobson DM, Trobe JD. The emerging role of magnetic resonance angiography in the management of patients with third cranial nerve palsy. Am J Ophthalmol 1999;128(1): Parks MM. Isolated cyclovertical muscle palsy. AMA Arch Opthalmol 1958;60(6): Zarwell TM, Chou B. Parks three step. In: Eye Dock A clinical reference for eye care professionals. Available at: eyedock.com/index.php?option=com_jumi&fileid=5&itemid=85. Accessed March 20, Keane JR. Fourth nerve palsy: historical review and study of 215 inpatients. Neurology 1993;43(12): Bendszus M, Beck A, Koltzenburg M, et al. MRI in isolated sixth nerve palsies. Neuroradiology 2001;43(9): Volpe NJ, Lee AG. Do patients with neurologically isolated ocular motor cranial nerve palsies require prompt neuroimaging? J Neuroophthalmol 2014;34(3): McClelland C, Van Stavern GP, Shepherd JB, Gordon M, Huecker J. Neuroimaging in patients referred to a neuro-ophthalmology service: the rates of appropriateness and concordance in interpretation. Ophthalmology 2012;119(8): Elmalem VI, Hudgins PA, Bruce BB, Newman NJ, Biousse V. Underdiagnosis of posterior communicating artery aneurysm in noninvasive brain vascular studies. J Neuroophthalmol 2011; 31(2): Volpe NJ, Lessell S. Remitting sixth nerve palsy in skull base tumors. Arch Ophthalmol 1993;111(10): Blitz AM, Macedo LL, Chonka ZD, et al. High-resolution CISS MR imaging with and without contrast for evaluation of the upper cranial nerves: segmental anatomy and selected pathologic conditions of the cisternal through extraforaminal segments. Neuroimaging Clin N Am 2014;24(1): Everton KL, Rassner UA, Osborn AG, Harnsberger HR. The oculomotor cistern: anatomy and high-resolution imaging. AJNR Am J Neuroradiol 2008;29(7): Seitz J, Held P, Strotzer M, et al. MR imaging of cranial nerve lesions using six different high-resolution T1- and T2( )-weighted 3D and 2D sequences. Acta Radiol 2002;43(4):

10 548 Kung, Van Stavern 42 Choi BS, Kim JH, Jung C, Hwang JM. High-resolution 3D MR imaging of the trochlear nerve. AJNR Am J Neuroradiol 2010; 31(6): Yousry I, Camelio S, Wiesmann M, et al. Detailed magnetic resonance imaging anatomy of the cisternal segment of the abducent nerve: Dorello s canal and neurovascular relationships and landmarks. J Neurosurg 1999;91(2): Yagi A, Sato N, Taketomi A, et al. Normal cranial nerves in the cavernous sinuses: contrast-enhanced three-dimensional constructive interference in the steady state MR imaging. AJNR Am J Neuroradiol 2005;26(4): Gelfand AA, Gelfand JM, Prabakhar P, Goadsby PJ. Ophthalmoplegic migraine or recurrent ophthalmoplegic cranial neuropathy: new cases and a systematic review. J Child Neurol 2012;27(6): Galtrey CM, Schon F, Nitkunan A. Microvascular non-arteritic ocular motor nerve palsies what we know and how should we treat? Neuroophthalmology 2015;39(1): Jacobson DM, McCanna TD, Layde PM. Risk factors for ischemic ocular motor nerve palsies. Arch Ophthalmol 1994;112(7): PatelSV,MutyalaS,LeskeDA,HodgeDO,HolmesJM.Incidence, associations, and evaluation of sixth nerve palsy using a population-based method. Ophthalmology 2004;111(2): Patel SV, Holmes JM, Hodge DO, Burke JP. Diabetes and hypertension in isolated sixth nerve palsy: a population-based study. Ophthalmology 2005;112(5): Jung JS, Kim DH. Risk factors and prognosis of isolated ischemic third, fourth, or sixth cranial nerve palsies in the Korean population. J Neuroophthalmol 2015;35(1): Sanders SK, Kawasaki A, Purvin VA. Long-term prognosis in patients with vasculopathic sixth nerve palsy. Am J Ophthalmol 2002;134(1): Capó H, Warren F, Kupersmith MJ. Evolution of oculomotor nerve palsies. J Clin Neuroophthalmol 1992;12(1): Jacobson DM, Broste SK. Early progression of ophthalmoplegia in patients with ischemic oculomotor nerve palsies. Arch Ophthalmol 1995;113(12): Jacobson DM. Progressive ophthalmoplegia with acute ischemic abducens nerve palsies. Am J Ophthalmol 1996;122(2): Wilker SC, Rucker JC, Newman NJ, Biousse V, Tomsak RL. Pain in ischaemic ocular motor cranial nerve palsies. Br J Ophthalmol 2009;93(12): Dreyfus PM, Hakim S, Adams RD. Diabetic ophthalmoplegia; report of case, with postmortem study and comments on vascular supply of human oculomotor nerve. AMA Arch Neurol Psychiatry 1957;77(4): Asbury AK, Aldredge H, Hershberg R, Fisher CM. Oculomotor palsy in diabetes mellitus: a clinico-pathological study. Brain 1970; 93(3): Weber RB, Daroff RB, Mackey EA. Pathology of oculomotor nerve palsy in diabetics. Neurology 1970;20(8): Bortolami R, D Alessandro R, Manni E. The origin of pain in ischemic-diabetic third-nerve palsy. Arch Neurol 1993;50(8): Phillips PH. Treatment of diplopia. Semin Neurol 2007;27(3): Johnson LN, Stetson SW, Krohel GB, Cipollo CL, Madsen RW. Aspirin use and the prevention of acute ischemic cranial nerve palsy. Am J Ophthalmol 2000;129(3): DeSantis D. Amblyopia. Pediatr Clin North Am 2014;61(3): Levi DM, Knill DC, Bavelier D. Stereopsis and amblyopia: a minireview. Vision Res 2015; Jan 29. [epub ahead of print] 64 Pratt-Johnson JA, Tillson G. Acquired central disruption of fusional amplitude. Ophthalmology 1979;86(12): Wylie J, Henderson M, Doyle M, Hickey-Dwyer M. Persistent binocular diplopia following cataract surgery: aetiology and management. Eye (Lond) 1994;8(Pt 5): Rawstron JA, Burley CD, Elder MJ. A systematic review of the applicability and efficacy of eye exercises. J Pediatr Ophthalmol Strabismus 2005;42(2):82 88

Management Approach to Isolated Ocular Motor Nerve Palsies

Management Approach to Isolated Ocular Motor Nerve Palsies Management Approach to Isolated Ocular Motor Nerve Palsies Alfredo A. Sadun, MD, PhD Thornton Professor of Vision Doheny Eye Institute Departments of Ophthalmology and Neurosurgery Keck/USC School of Medicine

More information

Fourth Nerve Palsy (a.k.a. Superior Oblique Palsy)

Fourth Nerve Palsy (a.k.a. Superior Oblique Palsy) Hypertropia Hypertropia is a type of strabismus characterized by vertical misalignment of the eyes. Among the many causes of vertical strabismus, one of the most common is a fourth nerve palsy (also known

More information

Doctor, I See Double : Managing Cranial Nerve Palsies

Doctor, I See Double : Managing Cranial Nerve Palsies 1 Doctor, I See Double : Managing Cranial Nerve Palsies Joseph W. Sowka, OD, FAAO, Diplomate Professor of Optometry Nova Southeastern University, College of Optometry 3200 South University Drive Fort Lauderdale,

More information

Pseudoabducens palsy: When a VI nerve palsy is not a VI nerve palsy

Pseudoabducens palsy: When a VI nerve palsy is not a VI nerve palsy Pseudoabducens palsy: When a VI nerve palsy is not a VI nerve palsy Emily S. Birkholz, MD, and Michael Wall, MD December 30, 2009 CC: 44 year old male with diplopia HPI: This 44 year old man with a history

More information

Original Article. A 3 Year Review of Cranial Nerve Palsies from the University of Port Harcourt Teaching Hospital Eye Clinic, Nigeria

Original Article. A 3 Year Review of Cranial Nerve Palsies from the University of Port Harcourt Teaching Hospital Eye Clinic, Nigeria Original Article A 3 Year Review of Cranial Nerve Palsies from the University of Port Harcourt Teaching Hospital Eye Clinic, Nigeria Chinyere Nnenne Pedro Egbe, Bassey Fiebai, Elizabeth Akon Awoyesuku

More information

Eye movement problems in adults

Eye movement problems in adults Eye movement problems in adults 07/12/2015 A. Dahlmann-Noor Dr med PhD FRCOphth FRCS(Ed) DipMedEd Consultant Ophthalmologist Clinical Trials Lead Paediatric Ophthalmology Horizontal misalignment (Cyclo)vertical

More information

Common visual symptoms and findings in MS: Clues and Identification

Common visual symptoms and findings in MS: Clues and Identification Common visual symptoms and findings in MS: Clues and Identification Teresa C Frohman, PA-C, MSCS Neuro-ophthalmology Research Manager, UT Southwestern Medical Center at Dallas Professor Biomedical Engineering,

More information

Paralytic Strabismus: Third, Fourth, and Sixth Nerve Palsy

Paralytic Strabismus: Third, Fourth, and Sixth Nerve Palsy Paralytic Strabismus: Third, Fourth, and Sixth Nerve Palsy Sashank Prasad, MD a, *, Nicholas J. Volpe, MD b KEYWORDS Paralytic strabismus Nerve palsy Ocular motor nerves Eye movement abnormalities ANATOMY

More information

Acute diplopia associated with systemic hypertension - A case Report

Acute diplopia associated with systemic hypertension - A case Report Standard Research Journal of Medicine and Medical Sciences Vol 3(2): 042-046, February 2015 (ISSN: 2409-0638) http://www.standresjournals.org/journals/srjmms Case Report Acute diplopia associated with

More information

Cranial Nerves. Cranial Nerve 1: Olfactory Nerve. Cranial Nerve 1: Olfactory Nerve. Cranial Nerve 2: Optic Nerve. Cranial Nerve 2: Optic Nerve

Cranial Nerves. Cranial Nerve 1: Olfactory Nerve. Cranial Nerve 1: Olfactory Nerve. Cranial Nerve 2: Optic Nerve. Cranial Nerve 2: Optic Nerve Cranial Nerves Examination of Cranial Nerves and Palsies Drs Nathan Kerr and Shenton Chew 1 Olfactory On 2 Optic Old 3 Oculomotor Olympus 4 Trochlear Towering 5 Trigeminal Top 6 Abducens A 7 Facial Finn

More information

Esotropia (Crossed Eye(s))

Esotropia (Crossed Eye(s)) Esotropia (Crossed Eye(s)) Esotropia is a type of strabismus or eye misalignment in which the eyes are "crossed," that is, while one eye looks straight ahead, the other eye is turned in toward the nose.

More information

Management of sixth nerve palsy different approaches

Management of sixth nerve palsy different approaches 100 Prună et al Management of sixth nerve palsy Management of sixth nerve palsy different approaches Violeta-Ioana Prună 1,4, Ligia Gabriela Tătăranu 3, V.M. Prună 2, Daniela Cioplean 4, R.M. Gorgan 3

More information

Primary Motor Pathway

Primary Motor Pathway Understanding Eye Movements Abdullah Moh. El-Menaisy, MD, FRCS Chief, Neuro-ophthalmology ophthalmology & Investigation Units, Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia Primary Motor Pathway

More information

Thyroid Eye Disease. Anatomy: There are 6 muscles that move your eye.

Thyroid Eye Disease. Anatomy: There are 6 muscles that move your eye. Thyroid Eye Disease Your doctor thinks you have thyroid orbitopathy. This is an autoimmune condition where your body's immune system is producing factors that stimulate enlargement of the muscles that

More information

Anatomy: The sella is a depression in the sphenoid bone that makes up part of the skull base located behind the eye sockets.

Anatomy: The sella is a depression in the sphenoid bone that makes up part of the skull base located behind the eye sockets. Pituitary Tumor Your doctor thinks you may have a pituitary tumor. Pituitary tumors are benign (non-cancerous) overgrowth of cells that make up the pituitary gland (the master gland that regulates other

More information

Vision Health: Conditions, Disorders & Treatments NEUROOPTHALMOLOGY

Vision Health: Conditions, Disorders & Treatments NEUROOPTHALMOLOGY Vision Health: Conditions, Disorders & Treatments NEUROOPTHALMOLOGY Neuroophthalmology focuses on conditions caused by brain or systemic abnormalities that result in visual disturbances, among other symptoms.

More information

PUPILS AND NEAR VISION. Akilesh Gokul PhD Research Fellow Department of Ophthalmology

PUPILS AND NEAR VISION. Akilesh Gokul PhD Research Fellow Department of Ophthalmology PUPILS AND NEAR VISION Akilesh Gokul PhD Research Fellow Department of Ophthalmology Iris Anatomy Two muscles: Radially oriented dilator (actually a myo-epithelium) - like the spokes of a wagon wheel Sphincter/constrictor

More information

List of diagnostic flowcharts

List of diagnostic flowcharts List of diagnostic flowcharts Chapter 3 Visual loss Transient visual loss 43 Sudden or rapidly progressive visual loss 46 Gradual visual loss 61 Chapter 4 The red eye One red eye, decreased vision 83 One

More information

Outcome of Surgery for Bilateral Third Nerve Palsy

Outcome of Surgery for Bilateral Third Nerve Palsy CLINICAL INVESTIGATIONS Outcome of Surgery for Bilateral Third Nerve Palsy Kazuhiro Aoki, Tatsushi Sakaue, Nobue Kubota and Toshio Maruo Department of Ophthalmology, Teikyo University School of Medicine,

More information

Diplopia, or double vision, is a frequently encountered. Binocular Diplopia. A Practical Approach ORIGINAL ARTICLE

Diplopia, or double vision, is a frequently encountered. Binocular Diplopia. A Practical Approach ORIGINAL ARTICLE ORIGINAL ARTICLE A Practical Approach Janet C. Rucker, MD, and Robert L. Tomsak, MD, PhD Background: Diplopia is a common complaint in both inpatient and outpatient neurologic practice. Its causes are

More information

Clinical Features of the Cranial Nerves Palsy Patients Attending at Neuro- Ophthalmology Department of a Tertiary Eye Care Hospital in Bangladesh

Clinical Features of the Cranial Nerves Palsy Patients Attending at Neuro- Ophthalmology Department of a Tertiary Eye Care Hospital in Bangladesh Original Article Clinical Features of the Cranial s Palsy Patients Attending at Neuro- Ophthalmology Department of a Tertiary Eye Care Hospital in Bangladesh ABSTRACT Dr. Tanima Roy, DCO Objective: There

More information

Exotropias: A Brief Review. Leila M. Khazaeni, MD November 2, 2008

Exotropias: A Brief Review. Leila M. Khazaeni, MD November 2, 2008 Exotropias: A Brief Review Leila M. Khazaeni, MD November 2, 2008 Exotropia Myths Myth #1 He/she will grow out of it FALSE 75% of XTs show progression over a 3 year period Myth #2 The only treatment choice

More information

How To Diagnose Stroke In Acute Vestibular Syndrome

How To Diagnose Stroke In Acute Vestibular Syndrome Danica Dummer, PT, DPT, University of Utah Abigail Reid, PT, DPT, Kessler Institute for Rehabilitation Online Journal Club-Article Review Article Citation Study Objective/Purpose (hypothesis) Study Design

More information

Guideline for the Management of Acute Peripheral Facial nerve palsy. Bells Palsy in Children

Guideline for the Management of Acute Peripheral Facial nerve palsy. Bells Palsy in Children Guideline for the Management of Acute Peripheral Facial nerve palsy Definition Bells Palsy in Children Bell palsy is an acute, idiopathic unilateral lower motor neurone facial nerve palsy that is not associated

More information

Surgical Outcome Of Incomitant Exotropia In Patients With Partial Third Nerve Palsy

Surgical Outcome Of Incomitant Exotropia In Patients With Partial Third Nerve Palsy Surgical Outcome Of Incomitant Exotropia In Patients With Partial Third Nerve Palsy Amit Mohan, MS ; Sudhir Singh, MS ; Dr V.C. Bhatnagar, MS, DNB Dr Amit Mohan, MS Jr.Consultant Global Hospital Institute

More information

Clinical guidance for MRI referral

Clinical guidance for MRI referral MRI for cervical radiculopathy Referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of spine for a patient 16 years or older for suspected: cervical radiculopathy

More information

Evaluation of Diplopia: An Anatomic and Systematic Approach

Evaluation of Diplopia: An Anatomic and Systematic Approach Clinical Review Article Evaluation of Diplopia: An Anatomic and Systematic Approach Victoria S. Pelak, MD Double vision, or diplopia, is a symptom with many potential causes that can involve many different

More information

Internuclear ophthalmoplegia: recovery and plasticity

Internuclear ophthalmoplegia: recovery and plasticity Internuclear ophthalmoplegia: recovery and plasticity M. J. Doslak, L. B. Kline, L. F. Dell'Osso, and R. B. Daroff We studied refixational eye movements of a patient during the gradual resolution of an

More information

DIAGNOSTIC CRITERIA OF STROKE

DIAGNOSTIC CRITERIA OF STROKE DIAGNOSTIC CRITERIA OF STROKE Diagnostic criteria are used to validate clinical diagnoses. Here below MONICA diagnostic criteria are reported. MONICA - MONItoring trends and determinants of CArdiovascular

More information

Original Contributions

Original Contributions doi:10.1016/j.jemermed.2007.04.020 The Journal of Emergency Medicine, Vol. 35, No. 3, pp. 239 246, 2008 Copyright 2008 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/08 $ see front matter

More information

Ptosis. Ptosis and Pupils. Ptosis. Palpebral fissure. Blepharospasm. Blepharospasm or ptosis? Bilateral, longstanding, familial: Palpebral fissure

Ptosis. Ptosis and Pupils. Ptosis. Palpebral fissure. Blepharospasm. Blepharospasm or ptosis? Bilateral, longstanding, familial: Palpebral fissure Ptosis and Pupils Ptosis Jack CF Chong, MS, MD 99/03/06 Ptosis Bilateral, longstanding, familial: CPEO (chronic progressive external ophthalmoplegia) D/D: Acute, recent, unilateral Palpebral fissure Palpebral

More information

The Work Up of Isolated Ocular Motor Palsy: Who to Scan and Why

The Work Up of Isolated Ocular Motor Palsy: Who to Scan and Why The Work Up of Isolated Ocular Motor Palsy: Who to Scan and Why Nicholas Volpe, MD Scheie Eye Institute, University of Pennsylvania Philadelphia, Pennsylvania LEARNING OBJECTIVES 1. To identify common

More information

UAMS / CAVHS Adult Neurology Neuro-Ophthalmology Curriculum 6/13/08

UAMS / CAVHS Adult Neurology Neuro-Ophthalmology Curriculum 6/13/08 UAMS / CAVHS Adult Neurology Neuro-Ophthalmology Curriculum 6/13/08 Summary Description of Rotation The adult neurology neuro-ophthalmology rotation is an extremely important rotation for 1 month during

More information

Short Communications. Isolated or Predominant Ocular Motor Nerve Palsy As a Manifestation of Brain Stem Stroke

Short Communications. Isolated or Predominant Ocular Motor Nerve Palsy As a Manifestation of Brain Stem Stroke Short Communications 581 Isolated or Predominant Ocular Motor Nerve Palsy As a Manifestation of Brain Stem Stroke Jong S. Kim, MD; Joong K. Kang, MD; Sang A. Lee, MD; and Myoung C. Lee, MD Background and

More information

Discovery of an Aneurysm Following a Motorcycle Accident. Maya Babu, MSIII Gillian Lieberman, M.D.

Discovery of an Aneurysm Following a Motorcycle Accident. Maya Babu, MSIII Gillian Lieberman, M.D. Discovery of an Aneurysm Following a Motorcycle Accident Maya Babu, MSIII Gillian Lieberman, M.D. Patient CC: July 2004 65 yo male transferred to the BI from an OSH s/p motorcycle crash w/o a helmet CC

More information

Neurology Clerkship Learning Objectives

Neurology Clerkship Learning Objectives Neurology Clerkship Learning Objectives Clinical skills Perform a neurological screening examination of the cranial nerves, motor system, reflexes, and sensory system under the observation and guidance

More information

What Is an Arteriovenous Malformation (AVM)?

What Is an Arteriovenous Malformation (AVM)? What Is an Arteriovenous Malformation (AVM)? From the Cerebrovascular Imaging and Intervention Committee of the American Heart Association Cardiovascular Council Randall T. Higashida, M.D., Chair 1 What

More information

Acute demyelinating optic neuritis Rod Foroozan, MD, Lawrence M. Buono, MD, Peter J. Savino, MD, and Robert C. Sergott, MD

Acute demyelinating optic neuritis Rod Foroozan, MD, Lawrence M. Buono, MD, Peter J. Savino, MD, and Robert C. Sergott, MD Acute demyelinating optic neuritis Rod Foroozan, MD, Lawrence M. Buono, MD, Peter J. Savino, MD, and Robert C. Sergott, MD Acute demyelinating optic neuritis associated with multiple sclerosis (MS) is

More information

Ocular motor nerve palsies: implications for diagnosis and mechanisms of repair

Ocular motor nerve palsies: implications for diagnosis and mechanisms of repair C. Kennard & R.J. Leigh (Eds.) Progress in Brain Research, Vol. 171 ISSN 0079-6123 Copyright r 2008 Elsevier B.V. All rights reserved CHAPTER 1.9 Ocular motor nerve palsies: implications for diagnosis

More information

PE finding: Left side extremities mild weakness No traumatic wound No bloody otorrhea, nor rhinorrhea

PE finding: Left side extremities mild weakness No traumatic wound No bloody otorrhea, nor rhinorrhea Case report A 82-year-old man was suffered from sudden onset spasm of extremities then he fell down to the ground with loss of consciousness. He recovered his consciousness 7-8 mins later but his conscious

More information

Differential Diagnosis of Craniofacial Pain

Differential Diagnosis of Craniofacial Pain 1. Differential Diagnosis of Craniofacial Pain 2. Headache Page - 1 3. International Headache Society International Classification... 4. The Primary Headaches (1-4) Page - 2 5. The Secondary Headaches

More information

What You Should Know About Cerebral Aneurysms

What You Should Know About Cerebral Aneurysms What You Should Know About Cerebral Aneurysms From the Cerebrovascular Imaging and Interventions Committee of the American Heart Association Cardiovascular Radiology Council Randall T. Higashida, M.D.,

More information

A Rare Image. Dean M. Cestari, MD Fred Jakobiec, MD Fred Hochberg, MD Joseph F. Rizzo III, MD Rebecca C. Stacy, MD PhD

A Rare Image. Dean M. Cestari, MD Fred Jakobiec, MD Fred Hochberg, MD Joseph F. Rizzo III, MD Rebecca C. Stacy, MD PhD A Rare Image Dean M. Cestari, MD Fred Jakobiec, MD Fred Hochberg, MD Joseph F. Rizzo III, MD Rebecca C. Stacy, MD PhD Harvard Neuro-ophthalmology Service Boston, Massachusetts 51 year-old male financial

More information

Angela Wilkin May 2013

Angela Wilkin May 2013 Angela Wilkin May 2013 Upper Motor Neuron v Lower Motor Neuron Lesions UMN Lesion LMN Lesion Forehead usually unaffected (bilateral innervation) Forehead affected Contralateral side Ipsilateral side Often

More information

Neurology. Chapter 6. The Eyes Have It. by Tim Root. Hey, buddy how many fingers am I holding up?

Neurology. Chapter 6. The Eyes Have It. by Tim Root. Hey, buddy how many fingers am I holding up? Chapter 6 Neurology The Eyes Have It I think my patient is faking blindness, but I can t tell. Let me see Hey, buddy how many fingers am I holding up? by Tim Root Definitely malingering. Neurology by Tim

More information

AMERICAN ACADEMY OF NEUROLOGY NEURO-OPHTHALMOLOGY/NEURO-OTOLOGY FELLOWSHIP CORE CURRICULUM

AMERICAN ACADEMY OF NEUROLOGY NEURO-OPHTHALMOLOGY/NEURO-OTOLOGY FELLOWSHIP CORE CURRICULUM AMERICAN ACADEMY OF NEUROLOGY NEURO-OPHTHALMOLOGY/NEURO-OTOLOGY FELLOWSHIP CORE CURRICULUM A CURRICULUM FOR NEURO-OPHTHALMOLOGY Definition and Scope Neuro-ophthalmology focuses on brain and systemic abnormalities

More information

Paediatric Bell s Palsy Paediatric Update November 2014

Paediatric Bell s Palsy Paediatric Update November 2014 Paediatric Bell s Palsy Paediatric Update November 2014 Richard Webster, Paediatric Neurologist Children s Hospital at Westmead Typical history Unilateral LMN facial weakness Acute onset over a day or

More information

Double Vision as a Presenting Symptom in an Ophthalmic Casualty Department

Double Vision as a Presenting Symptom in an Ophthalmic Casualty Department Eye (99) 5,-9 Double Vision as a Presenting Symptom in an Ophthalmic Casualty Department R. J. MORRIS London Summary All patients presenting with double vision as a principal symptom who presented to the

More information

Brain Spots on Imaging Tests

Brain Spots on Imaging Tests Brain Spots on Imaging Tests To Be or Not to Be Concerned Metropolitan Underwriting Discussion Group 1/29/13 Charles Levy, MD Aviva USA CT and MRI 2 most common forms of brain imaging today As with any

More information

3nd Biennial Contemporary Clinical Neurophysiological Symposium October 12, 2013 Fundamentals of NCS and NMJ Testing

3nd Biennial Contemporary Clinical Neurophysiological Symposium October 12, 2013 Fundamentals of NCS and NMJ Testing 3nd Biennial Contemporary Clinical Neurophysiological Symposium October 12, 2013 Fundamentals of NCS and NMJ Testing Peter D. Donofrio, M.D. Professor of Neurology Vanderbilt University Medical Center

More information

Do We Need a New Definition of Stroke & TIA as Proposed by the AHA? Stroke & TIA need to Remain Clinical Diagnoses: to Change Would be Bonkers!

Do We Need a New Definition of Stroke & TIA as Proposed by the AHA? Stroke & TIA need to Remain Clinical Diagnoses: to Change Would be Bonkers! Do We Need a New Definition of Stroke & TIA as Proposed by the AHA? No Stroke & TIA need to Remain Clinical Diagnoses: to Change Would be Bonkers! A/Prof Anne L. Abbott Neurologist School of Public Health

More information

Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: Neuroscience Center Baylor University Medical Center at Dallas

Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: Neuroscience Center Baylor University Medical Center at Dallas Billing and Coding in Neurology and Headache Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: Neuroscience Center Baylor University Medical Center at Dallas CPT Codes vs. ICD Codes Category

More information

STROKE PREVENTION AND TREATMENT MARK FISHER, MD PROFESSOR OF NEUROLOGY UC IRVINE

STROKE PREVENTION AND TREATMENT MARK FISHER, MD PROFESSOR OF NEUROLOGY UC IRVINE STROKE PREVENTION AND TREATMENT MARK FISHER, MD PROFESSOR OF NEUROLOGY UC IRVINE CASE REPORT: ACUTE STROKE MANAGEMENT 90 YEAR OLD WOMAN, PREVIOUSLY ACTIVE AND INDEPENDENT, CHRONIC ATRIAL FIBRILLATION,

More information

DIPLOPIA - DON T PANIC (JUST PUT ON YOUR THINKING CAP)

DIPLOPIA - DON T PANIC (JUST PUT ON YOUR THINKING CAP) DIPLOPIA - DON T PANIC (JUST PUT ON YOUR THINKING CAP) Lisa Rovick, CO, COMT This article and accompanying quiz are worth.5 JCAHPO Group A continuing education credit. CONTINUING EDUCATION CREDITS ARE

More information

09/05/2014. Painting pictures of the brain with numbers. Overview

09/05/2014. Painting pictures of the brain with numbers. Overview Painting pictures of the brain with numbers Neurology for Insurers Dr Ian Cox & Adele Groyer (Gen Re) Overview Critical Illness Product Background Why should we be interested in neurology? Consult our

More information

6.0 Management of Head Injuries for Maxillofacial SHOs

6.0 Management of Head Injuries for Maxillofacial SHOs 6.0 Management of Head Injuries for Maxillofacial SHOs As a Maxillofacial SHO you are not required to manage established head injury, however an awareness of the process is essential when dealing with

More information

Basic Cranial Nerve Examination

Basic Cranial Nerve Examination Basic Cranial Nerve Examination WIPE Wash hands Introduce yourself Permission Position (Patient sitting facing you, maintain comparable eye level) Exposure (Face exposed only, i.e. remove hats etc) Identify

More information

CLINICAL NEUROPHYSIOLOGY

CLINICAL NEUROPHYSIOLOGY CLINICAL NEUROPHYSIOLOGY Barry S. Oken, MD, Carter D. Wray MD Objectives: 1. Know the role of EMG/NCS in evaluating nerve and muscle function 2. Recognize common EEG findings and their significance 3.

More information

Isolated nontraumatic abducens nerve palsy

Isolated nontraumatic abducens nerve palsy Acta neurol. belg., 2007, 107, 126-130 Isolated nontraumatic abducens nerve palsy Vesna V. Brinar 1, Mario Habek 1, David Ozretić 2,Višnja Djaković 1 and Vesna Matijević 1 1 Referral Center for Demyelinating

More information

Institute of Ophthalmology. Thyroid Eye Disease. aka Thyroid Associated Ophthalmopathy

Institute of Ophthalmology. Thyroid Eye Disease. aka Thyroid Associated Ophthalmopathy Institute of Ophthalmology Thyroid Eye Disease aka Thyroid Associated Ophthalmopathy Causes TED/TAO is an eye disease associated with disease of the thyroid gland Most commonly, it occurs with an overactive

More information

EMG and the Electrodiagnostic Consultation for the Family Physician

EMG and the Electrodiagnostic Consultation for the Family Physician EMG and the Electrodiagnostic Consultation for the Family Physician Stephanie Kopey, D.O., P.T. 9/27/15 The American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) Marketing Committee

More information

CSE511 Brain & Memory Modeling. Lect04: Brain & Spine Neuroanatomy

CSE511 Brain & Memory Modeling. Lect04: Brain & Spine Neuroanatomy CSE511 Brain & Memory Modeling CSE511 Brain & Memory Modeling Lect02: BOSS Discrete Event Simulator Lect04: Brain & Spine Neuroanatomy Appendix of Purves et al., 4e Larry Wittie Computer Science, StonyBrook

More information

Sinus Headache vs. Migraine

Sinus Headache vs. Migraine Sinus Headache vs. Migraine John M. DelGaudio, MD, FACS Professor and Vice Chair Chief of Rhinology and Sinus Surgery Department of Otolaryngology Emory University School of Medicine 1 Sinus Headache Problems

More information

1 Always test and record vision wearing distance spectacles test each eye separately A 1mm pinhole will improve acuity in refractive errors

1 Always test and record vision wearing distance spectacles test each eye separately A 1mm pinhole will improve acuity in refractive errors Golden eye rules Examination techniques 1 Always test and record vision wearing distance spectacles test each eye separately A 1mm pinhole will improve acuity in refractive errors Snellen chart (6 metre)

More information

RAPID CLINICAL REPORT

RAPID CLINICAL REPORT RAPID CLINICAL REPORT ADVERSE EFFECTS ASSOCIATED WITH THE ABSENCE OF HYALURONIDASE IN ANESTHESIA FOR CATARACT SURGERY Background: Issued February 13, 2001 Hyaluronidase (Wydase ) is a medical preparation

More information

Torsional Diplopia 1,2

Torsional Diplopia 1,2 Supplement Handout American Orthoptic Council Workshop: When the Patient Sees Double and the Doctor Sees Nothing A Guide to Double Vision AAPOS 37 th Annual Meeting San Diego, CA April 1, 2011 Torsional

More information

Parts of the Brain. Chapter 1

Parts of the Brain. Chapter 1 Chapter 1 Parts of the Brain Living creatures are made up of cells. Groups of cells, similar in appearance and with the same function, form tissue. The brain is a soft mass of supportive tissues and nerve

More information

CONGENITAL NYSTAGMUS WHEN TO RECORD HOW TO TREAT 2009

CONGENITAL NYSTAGMUS WHEN TO RECORD HOW TO TREAT 2009 CONGENITAL NYSTAGMUS WHEN TO RECORD HOW TO TREAT 2009 LIONEL KOWAL Royal Victorian Eye and Ear Hospital Center for Eye Research Australia Melbourne, Australia TYPES OF CONGENITAL NYSTAGMUS cn cn: any type

More information

Complications of Strabismus Surgery

Complications of Strabismus Surgery Complications of Strabismus Surgery Tjeerd de Faber, Martha Tjon Rutger van Ruyven Alexis Damanakis Ondercorrectie Overcorrectie Wat vind je erger? 1 DELLEN Corneal dellen are small areas of thinning associated

More information

Case Report. Central Neurocytoma. Fotis Souslian, MD; Dino Terzic, MD; Ramachandra Tummala, MD. Department of Neurosurgery, University of Minnesota

Case Report. Central Neurocytoma. Fotis Souslian, MD; Dino Terzic, MD; Ramachandra Tummala, MD. Department of Neurosurgery, University of Minnesota 1 Case Report Central Neurocytoma Fotis, MD; Dino Terzic, MD; Ramachandra Tummala, MD Department of Neurosurgery, University of Minnesota Case This is a previously healthy 20 year old female, with 3 months

More information

Ophthalmoplegic Migraine: Still a Diagnostic Dilemma?

Ophthalmoplegic Migraine: Still a Diagnostic Dilemma? Ophthalmoplegic Migraine: Still a Diagnostic Dilemma? K. Ravishankar, MD Corresponding author K. Ravishankar, MD The Headache and Migraine Clinic, Jaslok Hospital and Research Centre, Lilavati Hospital

More information

NEURO MRI PROTOCOLS TABLE OF CONTENTS

NEURO MRI PROTOCOLS TABLE OF CONTENTS TABLE OF CONTENTS NEURO MRI PROTOCOLS BRAIN...2 Brain 1 Screen... 2 Brain 2 Brain Tumor... 2 Brain 3 Brain Infection / Meningitis... 2 Brain 4 Trauma... 3 Brain 5 Hemorrhage... 3 Brain 6 Demyelinating

More information

MANAGEMENT OF VITH NERVE PALSY-AVOIDING UNNECESSARY SURGERY

MANAGEMENT OF VITH NERVE PALSY-AVOIDING UNNECESSARY SURGERY MANAGEMENT OF VITH NERVE PALSY-AVOIDING UNNECESSARY SURGERY P. RIORDAN-E VA and J. P. LEE London SUMMARY Unresolved Vlth nerve palsy that is not adequately controlled by an abnormal head posture or prisms

More information

Thyroid Eye Disease. A Patient s Guide

Thyroid Eye Disease. A Patient s Guide Sashank Prasad, MD www.brighamandwomens.org/neuro-ophthalmology A Patient s Guide Symptoms Diagnosis Treatment Prognosis What are the symptoms of Thyroid Eye Disease? Patients with Thyroid Eye Disease

More information

Program Requirements for Fellowship Education in Neuro- Ophthalmology

Program Requirements for Fellowship Education in Neuro- Ophthalmology Program Requirements for Fellowship Education in Neuro- Ophthalmology [M] = Must have / required [S] = Should have I. Introduction A. Definition and Scope of Neuro ophthalmology Neuro ophthalmology is

More information

THE EYES IN MARFAN SYNDROME

THE EYES IN MARFAN SYNDROME THE EYES IN MARFAN SYNDROME Marfan syndrome and some related disorders can affect the eyes in many ways, causing dislocated lenses and other eye problems that can affect your sight. Except for dislocated

More information

Social Security Disability Insurance and young onset dementia: A guide for employers and employees

Social Security Disability Insurance and young onset dementia: A guide for employers and employees Social Security Disability Insurance and young onset dementia: A guide for employers and employees What is Social Security Disability Insurance? Social Security Disability Insurance (SSDI) is a payroll

More information

Disability Evaluation Under Social Security

Disability Evaluation Under Social Security Disability Evaluation Under Social Security Revised Medical Criteria for Evaluating Endocrine Disorders Effective June 7, 2011 Why a Revision? Social Security revisions reflect: SSA s adjudicative experience.

More information

Article. Diagnosis of a Superior Rectus Overaction After Cataract Surgery

Article. Diagnosis of a Superior Rectus Overaction After Cataract Surgery Article Diagnosis of a Superior Rectus Overaction After Cataract Surgery Angel F. Romero Ayala, OD Assistant Professor, Interamerican University of Puerto Rico, School of Optometry ABSTRACT Background.

More information

3) Cerebral Cortex & Functions of the 4 LOBES. 5) Cranial Nerves (Nerves In the Cranium, i.e., Head)

3) Cerebral Cortex & Functions of the 4 LOBES. 5) Cranial Nerves (Nerves In the Cranium, i.e., Head) Lecture 5 (Oct 8 th ): ANATOMY and FUNCTION OF THE NERVOUS SYSTEM Lecture Outline 1) Basic Divisions (CNS vs. PNS, Somatic vs. Autonomic) and Directional Terms 2) The Brain (Hindbrain/ Midbrain/ Forebrain)

More information

Graduate Diploma in Optometry. Related modules Pre-requisites Satisfying requirements of second year BSc (Hons) Optometry examination board

Graduate Diploma in Optometry. Related modules Pre-requisites Satisfying requirements of second year BSc (Hons) Optometry examination board Posterior Eye & General Ophthalmology School and subject group Module code Module title Module type Module replaces (where appropriate) Life and Health Sciences / Optometry OP3PEG Posterior Eye & General

More information

Physical and Mental Conditions Guidelines VISION CONDITIONS AND ACTIONS Page 5.4

Physical and Mental Conditions Guidelines VISION CONDITIONS AND ACTIONS Page 5.4 Physical and Mental Conditions Guidelines VISION CONDITIONS AND ACTIONS Page 5.4 AMBLYOPIA (Lazy Eye) A reduction in the acuteness of vision without apparent eye disease. This condition cannot be entirely

More information

6/3/2011. High Prevalence and Incidence. Low back pain is 5 th most common reason for all physician office visits in the U.S.

6/3/2011. High Prevalence and Incidence. Low back pain is 5 th most common reason for all physician office visits in the U.S. High Prevalence and Incidence Prevalence 85% of Americans will experience low back pain at some time in their life. Incidence 5% annual Timothy C. Shen, M.D. Physical Medicine and Rehabilitation Sub-specialty

More information

Reversibility of Acute Demyelinating Lesions in relapsingremitting

Reversibility of Acute Demyelinating Lesions in relapsingremitting Reversibility of Acute Demyelinating Lesions in relapsingremitting Multiple Sclerosis Omar A. Khan ( Division of Neuroimmunology, Department of Neurology, Neurology and Research Services. Veterans Affairs

More information

Vision and Rehabilitation After Brain Trauma Eric Singman, MD, PhD, Health.mil

Vision and Rehabilitation After Brain Trauma Eric Singman, MD, PhD, Health.mil Vision and Rehabilitation After Brain Trauma Eric Singman, MD, PhD, Health.mil This article was first accessed at Brainline.org. Vision Problems After Brain Injury Visual problems following brain trauma

More information

THE EYES IN CHARGE: FOR THE OPHTHALMOLOGIST Roberta A. Pagon, M.D. Division of Medical Genetics, CH-25, Children's Hospital /Medical Center, Box C5371, Seattle, WA 98105-0371 bpagon@u.washington.edu (206)

More information

HEADACHES AND THE THIRD OCCIPITAL NERVE

HEADACHES AND THE THIRD OCCIPITAL NERVE HEADACHES AND THE THIRD OCCIPITAL NERVE Edward Babigumira M.D. FAAPMR. Interventional Pain Management, Lincoln. B. Pain Clinic, Ltd. Diplomate ABPMR. Board Certified Pain Medicine No disclosures Disclosure

More information

Summary Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in People with Multiple Sclerosis (MS)

Summary Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in People with Multiple Sclerosis (MS) ETMIS 2012; Vol. 8: N o 7 Summary Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in People with Multiple Sclerosis (MS) March 2012 A production of the Institut national d

More information

FastTest. You ve read the book... ... now test yourself

FastTest. You ve read the book... ... now test yourself FastTest You ve read the book...... now test yourself To ensure you have learned the key points that will improve your patient care, read the authors questions below. The answers will refer you back to

More information

Thyroid eye disease (TED)

Thyroid eye disease (TED) Thyroid eye disease (TED) Mr David H Verity, MD MA FRCOphth Consultant Ophthalmic Surgeon Synonyms: Graves ophthalmopathy, thyroid ophthalmopathy, thyroid associated ophthalmopathy This information leaflet

More information

Management of spinal cord compression

Management of spinal cord compression Management of spinal cord compression (SUMMARY) Main points a) On diagnosis, all patients should receive dexamethasone 10mg IV one dose, then 4mg every 6h. then switched to oral dose and tapered as tolerated

More information

Trauma Insurance Claims Seminar Invitation

Trauma Insurance Claims Seminar Invitation Trauma Insurance Claims Seminar Invitation Introduction Since the development of Trauma Insurance in Australia in the 1980s, the product has evolved at a great pace. Some of the challenges faced by claims

More information

Neuro-Ophthalmology. Bascom Palmer s clinical detectives study the links between brain and eye. The super sleuths of vision. 2Neuro-Ophthalmology

Neuro-Ophthalmology. Bascom Palmer s clinical detectives study the links between brain and eye. The super sleuths of vision. 2Neuro-Ophthalmology 2Neuro-Ophthalmology The super sleuths of vision Neuro-Ophthalmology Bascom Palmer s clinical detectives study the links between brain and eye When Miguel Cabrera became concerned about a drooping eyelid

More information

Neuroimaging of Headache. Kenneth D. Williams, MD

Neuroimaging of Headache. Kenneth D. Williams, MD Neuroimaging of Headache Kenneth D. Williams, MD Disclosures Financial: None Off Label Usage: None Key Points Headache is an extremely common symptom. Structural abnormalities (Primary HA) are rare. Clinical

More information

Orbit & Cranial Nerves II, III, IV, & VI

Orbit & Cranial Nerves II, III, IV, & VI Orbit & Cranial Nerves II, III, IV, & VI PCC Year 1, Spring Quarter Lawrence M. Witmer, PhD Life Sciences Building 123 OBJECTIVES: to understand the anatomy of the bony orbit and its contents, in particular,

More information

APPENDIX A NEUROLOGIST S GUIDE TO USING ICD-9-CM CODES FOR CEREBROVASCULAR DISEASES INTRODUCTION

APPENDIX A NEUROLOGIST S GUIDE TO USING ICD-9-CM CODES FOR CEREBROVASCULAR DISEASES INTRODUCTION APPENDIX A NEUROLOGIST S GUIDE TO USING ICD-9-CM CODES FOR CEREBROVASCULAR DISEASES INTRODUCTION ICD-9-CM codes for cerebrovascular diseases is not user friendly. This presentation is designed to assist

More information

Epilepsy 101: Getting Started

Epilepsy 101: Getting Started American Epilepsy Society 1 Epilepsy 101 for nurses has been developed by the American Epilepsy Society to prepare professional nurses to understand the general issues, concerns and needs of people with

More information

Optic Disc Drusen. Normal Enlarged view of Optic Disc. Lumpy Appearance of Optic Disc. Optic Disc Drusen With Drusen

Optic Disc Drusen. Normal Enlarged view of Optic Disc. Lumpy Appearance of Optic Disc. Optic Disc Drusen With Drusen Optic Disc Drusen Your doctor has diagnosed you with optic disc drusen. Optic disc drusen are abnormal deposits of protein-like material in the optic disc the front part of the optic nerve. We do not know

More information

a guide to understanding facial palsy a publication of children s craniofacial association

a guide to understanding facial palsy a publication of children s craniofacial association a guide to understanding facial palsy a publication of children s craniofacial association a guide to understanding facial palsy this parent s guide to facial palsy is designed to answer questions that

More information